Osteopathy Journals and Research by Darren Chandler

 

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  1. Entrapment neuropathies in the upper extremity

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    Median nerve (Meyer et al 2018)

    Anatomy of the median nerve

    Nerve roots and cords

    Lateral cord (C6 & C7) Medial cord (C8 & T1).

    Fibers in the lateral cord (from the lateral roots) convey most of the sympathetic fibers to the median distribution of the hand (Standring 2017).

    Trunk

    After originating from the brachial plexus in the axilla, the median nerve lies laterally the brachial artery and then crosses it anteriorly to medially.

    The lower head of the coracobrachialis which is usually suppressed in human beings is sometimes present as the ligament of Struthers. The Median nerve and brachial artery passes deep to this ligament.

    After entering the cubital fossa the nerve passes in relation to:

    • Bicipital aponeurosis (aka lacertus fibrosus): the nerve passes beneath the bicipital aponeurosis.

    • Brachialis: passes over the brachialis

    • Pronator teres: passes between the two heads of the pronator teres.

    In the anterior antebrachial compartment the nerve passes in relation to:

    • Flexor digitorium superficialis: runs under the aponeurotic arch of the flexor digitorum superficialis. Just proximal to the aponeurotic arch of the flexor digitorium superficialis the median nerve gives off the anterior interosseous nerve which innervates the deep flexors.

    • Flexor digitorum superficialis and profundus: before coursing between the flexor digitorum superficialis and profundus muscles.

    In the distal forearm, 3cm proximal to the wrist crease, the median nerve gives rise to the palmar cutaneous branch, which provides sensory innervation to the skin on the proximal side of the palm.

    In the wrist the median nerve passes under the flexor retinaculum into the carpal tunnel.

    Distal to the carpal tunnel, the median nerve subdivides into five branches: the recurrent motor branch to muscles of the thenar compartment and four digital sensory branches.

    The median nerve is palpable:

    • After emerging from the coracobrachialis.
    • Deep to the bicipital aponeurosis.
    • At the wrist where it emerges from behind the superficial flexor tendons just lateral to the palmatris longus.

    Innervation

    Motor function to the forearm.

    Motor and sensory function to the wrist and hand.

    Cutaneous innervation: thenar eminence, lateral side of the palm, palmar side of the 1-3 fingers and lateral 4.

    Anatomy of the carpal tunnel

    The boundaries of the carpal tunnel are:

    • Posteriorly: carpal bones.
    • Laterally: tubercle of scaphoid and trapezium.
    • Medially: pisiform and hook of the hamate.
    • Anterior: the roof of the tunnel is the transverse carpal ligament or flexor retinaculum. Divided into two layers (1) Superficial. Formed by the palmaris brevis tendon (2) Deep. Made up of transversal fibers.

    The carpal tunnel contains:

    • Tendons: flexor pollicis longus, the four flexor digitorum superficialis and the four flexor digitorum profundus tendons.
    • Neurological: median nerve. Travels between the flexor retinaculum and the flexor tendons of 2 and 3 fingers.

    Entrapment sites of the median nerve

    Entrapement sites of the median nerve are:

    • Carpal tunnel: 90-93% of entrapment of the median nerve.

    • Supracondylar process continued by the ligament of Struthers: The ligament of Struthers is a fibrous band connecting the supracondylar process to the medial epicondyle, encasing neurovascular structures [3] including the median nerve and the brachial artery but also the ulnar nerve, the ulnar artery and a branch of the musculocutaneous nerve.

    • The bicipital aponeurosis (lacertus fibrosus): extends from the myotendinous junction of the distal biceps to the medial deep fascia of the forearm close to the epicondylar muscles. Covers the median nerve and the brachial artery.

    • Pronator teres: between the humeral and ulnar heads of the pronator teres.

    • Fibrous arch of the origin of the flexor digitorum superficialis.

    Anatomical variations in the forearm causing entrapment of the median nerve.

    • Accessory head of the flexor pollicis longus.

    • Accessory head of the flexor digitorum profundus.

    • Bicipital bursa.

    Anatomical variations in the carpal tunnel causing entrapment of the carpal tunnel:

    • Accessory palmaris longus.

    • Accessory palmaris profundus.

    • Accessory flexor digitorum muscle.

    • Accessory lumbricals.

    Ulnar nerve (Choi et al (2018)

    Anatomy of the ulnar nerve

    Nerve root and cords

    (C7: lateral cord) C8-T1: medial cord.

    Trunk

    Travels medial to the brachial arttery up until the insertion of the coracobrachialis. It then pierces the medial intermuscular spetum 10cm proximal to the medial epicondyle, to enter the posterior compartment of the arm.

    It then passes through a fibrous canal (arcade of Struthers). The walls of this canal is the medial intermuscular septum and fascial sheath invetsing the medial head of triceps. The myofascial pain pattern of the medial head of triceps are similiar to that of ulnar nerve symptoms.

    It then continues posterior to the medial epicondyle in the cubital tunnel.

    After leaving the cubital tunnel the ulanr nerve crosses the medial collateral ligament of the elbow before entering the forearm.

    Ulnar nerve entered the forearm between the humeral origin (on the medial epicondyle) and ulnar origin of the flexor carpi ulnaris.

    The nerve then traveled into a deep fascia septum between the anterior surface of the flexor carpi ulnaris and the posterior surface of the flexor digitorum superficialis. The deep fascia is an anatomically tough structure that lies immediately against the course of the ulnar nerve.

    The ulnar branches to the flexor carpi ulnaris arose proximal to the septum between the flexor carpi ulnaris and flexor digitorum superficialis.

    More distally branches to the flexor digitorum profundus pierced this fascial septum while en route to the posterior surface of this muscle’s ulnar one half.

    The dorsal cutaneous nerve arises from the ulnar nerve 6cm proximal to the ulnar styloid process.

    At the wrist the ulnar nerve divides into superficial (sensory) and deep (motor) components both of which pass through Guyon's canal.

    The ulnar nerve is palpable at:

    • Posterior to the medial epicondyle.
    • At the worst as it emerges from under the flexor carpi ulnaris.

    Anatomy of the cubital tunnel

    Machhi et al (2014) identified the cubital tunnel as being bordered by:

    • Medially: humeral and ulna heads of the flexor carpi ulnaris.
    • Anteriorly: medial epicondyle.
    • Roof: arcuate ligament of Osborne (medial epicondyle --> medial aspect of olecranon process).

    Anatomy of the Guyons's canal

    Guyon's canal is a fibrosseous tunnel. It's formed by the transverse carpal ligament at the proximal aspect of the pisiform --> origin of the hypothenar eminence at the hook of the hamate.

    Sites of entrapment

    • Cubital tunnel.

    • Flexor/pronator muscle origin: formation of “tendinous bands” at the humeral and ulnar head of the flexor carpi ulanris/pronator muscle origin.

    • Medial intermuscular septum: the medial intermuscular septum runs between the flexor carpi ulnaris and flexor digitorum profundus muscles. The ulnar nerve can suffer promixmal and distal compression by the medial intermuscular septum.

    • Intermuscular aponeurosis between the flexor digitorum superficialis and flexor carpi ulnaris.

    • Deep fascia septum between the anterior surface of the flexor carpi ulnaris and the posterior surface of the flexor digitorum superficialis: whilst Choi et al (2018) found no ulnar nerve compression by this fascial septum with elbow extension some angulation of the proximal ulnar nerve was noted due to its intimate connection to the deep fascia.

    • Fibrous aponeurosis between the flexor digitorum superficialis and the humeral head of the flexor carpi ulnaris. 

    • Anconeus epitrochlearis muscle (Macchi et al 2014).

    References

    The Median Nerve at the Carpal Tunnel … and Elsewhere (2018). Philippe MeyerPierre-Francois LintingreLionel PesquerNicolas PoussangeAlain Silvestre, and Benjamin Dallaudière.

    The Deep Fascia of the Forearm and the Ulnar Nerve: An Anatomical Study (2018). Paul J ChoiChidinma NwaogbeJoe IwanagaGeorgi P GeorgievRod J Oskouian, and R. Shane Tubbs.

  2. Axial Spondyloarthritis (Ankylosing Spondylitis) Screening

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    Axial Spondyloarthritis (AxSpA) Screening

    This is based on the SPADE tool by Zoe Clark osteopath:

    Patient Name:

    DOB: 

    • Did your back pain and stiffness start before the age of 45?
    • Did your pain and stiffness develop gradually, with symptoms persisting at least three months?
    • Does your pain and stiffness tend to ease with physical activity and exercise?
    • Do you find there is no improvement in your back pain when you rest?
    • Do you suffer from increased back pain and discomfort when immobile during sleep, and start to feel better once up and moving?
    • Does the pain improve with NSAIDs?
    • Do you experience fatigue?
    • Do you have/have you had heel pain (enthesitis)?
    • Do you have peripheral arthritis/other joint pains or swellings? Do you have/have you had dactylitis?
    • Do you have a history of iritis/uveitis?
    • Do you have psoriasis?
    • Do you have inflammatory bowel disease (Crohn’s or Ulcerative Colitis)?
    • Do you have a family history of: - Axial SpA? - Reactive Arthritis? - Psoriasis? - IBD (Crohn’s or Ulcerative Colitis)? - Uveitis?
    • Have you had a blood test for ESR or CRP? If so, were they raised?
    • Are you HLA-B27 positive?
    • Do you have sacroiliitis shown by MRI?